The budget passed the N.C. House in a controversial veto override, but the debate over Medicaid expansion is far from over. 

House Speaker Tim Moore, R-Cleveland, promised a vote on Medicaid expansion after a veto override passed. He said members will debate the Republican version of the plan, House Bill 655, this week. The Senate, for its part, still needs to override Gov. Roy Cooper’s veto of the $24 billion General Fund budget, and it needs to woo one Democrat to buck Cooper before doing so. 

The surprise override Wednesday, Sept. 11, provoked the wrath of Cooper and other Democrats. The Democrats had made Medicaid expansion a sticking point during budget negotiations. But with the budget no longer stuck in the House, Democrats may have lost much of their leverage. 

“Republicans waged an assault on our democracy, they cheated the people of North Carolina,” Cooper tweeted, later calling the override “illegal” and lamenting Medicaid expansion.  

Moore said the House would consider the Republican version of Medicaid expansion, called N.C. Health Care for Working Families.

It was on the House Health Committee’s agenda for Tuesday, Sept. 17. But it was removed Friday from the calendar.

The Senate hasn’t scheduled a vote on the override. House leaders may prevent the bill from undergoing committee revisions — let alone a floor vote — until the override prevails.

H.B. 655 is the newest incarnation of the Medicaid expansion Rep. Donny Lambeth, R-Forsyth, has been pushing for almost three years. It had been parked on the House calendar for weeks. 

“I feel the same way today that I did when I started. It’s a long shot,” Lambeth said. “I feel like it has a reasonable chance in the House, but we’ll see what happens in the Senate.” 

Lambeth is eager to distinguish his bill from traditional Medicaid expansion. The bones of his program are identical. It would open Medicaid to those earning up to 138% of the poverty line, enrolling between 500,000 and 600,000 people and spending $6 billion in the next decade. Uncle Sam (federal taxpayers) would pick up 90% of the tab. 

Currently, only people who fit into several narrow categories — those with children, or who are pregnant, disabled, or elderly — qualify for Medicaid. Simply being low-income doesn’t qualify. 

Like Cooper’s proposal, Lambeth’s bill would expand Medicaid to cover low-income adults, or individuals earning $16,753 and a family of four making $34,638 in 2019. 

But unlike Cooper’s version, Lambeth’s program includes measures meant to make expansion more palatable to Republicans. He said it shields the state’s budget by shifting the state’s share of the cost onto providers, hospitals, and enrollees themselves. 

“There’s no state funding,” Lambeth said. “No state money.”

The bill contains a premium capped at 2% of income, a work requirement, a focus on preventive care, and a grant program designed to funnel money into struggling rural hospitals.

“It only resembles expansion in a couple of areas,” Lambeth said. “I’ve tried to design a product that looks more like an insurance option.”

But work requirements are tangled in the courts, and their future remains uncertain. Kentucky, Arkansas, and New Hampshire all tried to slap work requirements on Medicaid expansion, and all were shot down in federal court. 

“The modifications in the plan — the work requirements and the premiums — both have questionable standing,” John Locke Foundation analyst Joseph Coletti said. “In every state that has tried to do work requirements, they are on hold. And if the states actually try to enforce a premium, it’s been struck down. … So you’re basically in the same spot where you started: where the governor wants to be.”

The Senate GOP leadership is skeptical of Lambeth’s plan, criticizing it for mimicking Cooper’s full Medicaid expansion.

“The House is working on some changes, so we will have to see what the bill looks like after that,” Bill D’Elia, a spokesman for Senate leader Phil Berger, R-Rockingham, said in a statement. “However, in its current form it still raises many of the same concerns for Senator Berger that regular Medicaid expansion does.” 

The hospitals support Lambeth. The N.C. Healthcare Association has endorsed expansion, arguing it would save rural hospitals by slashing the number of uninsured patients. 

“People who have health care coverage are more likely to see a health care provider when they are sick and get prescriptions filled,” said Leah Burns, NCHA government relations director. “They are more likely to use appropriate health care settings for care. 

“A healthier population is good not only for individuals and their families, but also for employers and everyone else.”

Other red states have softened their stance on Medicaid expansion. Idaho, Utah, and Nebraska expanded Medicaid in 2018. 

Lambeth said he thinks the bill can make it through the House, but called the Senate a “challenge.”

Berger has staunchly opposed expansion in the past. 

“Everyone agrees that ways to increase access to health care is something we need to discuss, but there is not a consensus about what the best way to accomplish that is,” D’Elia said.